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Browse POLICY Project (1995-2006) Materials

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Working Papers

  • Although contraceptive use has risen impressively in many countries over the last few decades, there have been occasional flat periods that have raised serious concerns about the effectiveness of the national family planning programs involved. Of special concern are a few instances in the Asia and Near East region, where interruptions of an established upward trend in contraceptive use have raised troubling policy and program questions for both governments and international donor agencies. Issues exist concerning the actual frequency of plateaus in contraceptive increase, why they occur, why most are so brief, and what actions should be taken when they occur. The analysis reported here uses a large set of national surveys to explore especially the first of those questions and to offer suggestions as to the other three.
  • The role of policy in improving program outcomes in the family planning/reproductive health (FP/RH), safe motherhood, and HIV/AIDS fields has been increasingly recognized. Despite this increased recognition, “policy” is often seen as a black box. Existing frameworks or models focus on some aspects of policy—the stages of policy development, decision makers and stakeholder institutions, the intent and content of a policy, or its implementation—yet none captures all policy components. This paper provides a practical framework to analyze components of family planning, reproductive health, maternal health, and HIV/AIDS policies. The Policy Circle framework is presented and the six “Ps” of policy are described: Problem, People/Places, Process, Price Tag, Paper, and Programs/Performance. Each component of the Policy Circle can be analyzed using a variety of tools. The Policy Circle is not intended to be linear or even circular, but places the problem or issue to be solved at the center. The six policy “Ps” of the Policy Circle operate under the broader contextual forces of politics, society, and economics. The Policy Circle has wide applicability. The proposed framework can be used to analyze different policy levels, including national and local policies and sectoral and operational policies. In the case of FP/RH, the Policy Circle can be viewed through different lenses specific to three overarching concerns: youth, gender, and human rights. Each of the six “Ps” points to important aspects of policy that need to be considered to ensure comprehensive policy analysis of the issue or area of concern to which the Policy Circle is applied. Visit the Policy Circle online - click here
  • Nigeria is in the early stages of carrying out its new national policy on sexuality and reproductive health education. Worldwide, school-based programs are an important element of efforts to improve the reproductive health of young people. This paper reviews the international experience and its implications for Nigeria.
  • In 1994, after three decades of donor support to Turkey’s national family program, the U.S. Agency for International Development (USAID) announced its intention to phase out assistance. On the eve of donor phaseout, Turkey’s public sector program was serving nearly 60 percent of the market for modern family planning methods, including many nonpoor clients. During the transition period, the Ministry of Health was challenged not only to obtain new resources to replace donated contraceptive commodities but also to assume new technical responsibilities for the program. The story of how the ministry succeeded is often told in technical terms (e.g., number of procurements, budget trends, pilot project design, etc.). An equally important part of the story is the political and institutional context within which success was achieved. Examining how the MCH-FP Directorate overcame challenges to put in place a sustainable strategy for the public sector family planning program reveals the political dimensions of the process. Using a political economy framework, this paper examines the processes that led to implementation two central components of Turkey’s national self-reliance strategy: obtaining annual budget allocations for contraceptives and targeting free services to the poor. The framework used here to analyze the process of formulating and adopting Turkey’s contraceptive self-reliance strategy has five components: stakeholders’ characteristics, institutional characteristics, contextual conditions, process characteristics, and reform characteristics.
  • The Greater Involvement of People Living with HIV/AIDS (GIPA) principle has become the most enduring legacy of the Paris Declaration. GIPA has been incorporated into national and international program and policy responses and taken up as a model of best practice in the response to HIV/AIDS. Since the Paris Summit in December 1994, GIPA has been endorsed in numerous international statements, most recently by the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in its Declaration of Commitment on HIV/AIDS (United Nations, 2001). Ten years after the Paris Summit, the issue of meaningful involvement of people living with HIV/AIDS (PLHAs) in policy development remains largely unexplored. A number of questions linger: Has GIPA become a “bandwagon” policy slogan without significant meaning? What are the benefits of adhering to the GIPA principle and does this lead to better policies? How do PLHAs and others measure and determine progress? To answer these questions, the POLICY Project conducted a study of PLHA involvement in five countries. This report seeks to address how PLHAs are meaningfully involved in policy formulation by exploring key issues related to the GIPA principle and its effects.
  • The research reported here concerns the Maternal and Neonatal Program Effort Index (MNPI), a standardized assessment instrument applied in both 1999 and 2002. Previous reports cover the detailed methodology and the results from the 1999 study, as well as the relation of the MNPI ratings to maternal mortality ratios (Ross, Campbell, and Bulatao, 2001; Bulatao and Ross, 2002; Bulatao and Ross, 2003a). The MNPI instrument is designed to measure the strength and character of government programs to improve maternal health. It contains items for the most proximate determinants of maternal survival, including those related to emergency obstetric and abortion cases, as well as the less proximate determinants of the policies and institutional arrangements necessary to build treatment capacities. Capturing these program features can document the low effort levels that now exist and create a baseline against which to trace future improvements. The overall purpose is to measure program inputs and strength of effort for the reduction of maternal mortality and morbidity and closely related neonatal items.
  • User fees are gaining widespread use in government health programs as a means of alleviating pressure on constrained budgets as demand for services increases. Concerns that fees reduce access to services among the poor have led to the promotion of fee exemption mechanisms in order to protect those unable to pay for services. The exemptions, however, may not effectively ensure access among the poor because (1) informal fees and other costs associated with seeking and receiving services are not alleviated by most exemption mechanisms and (2) exemption mechanisms are poorly implemented. The low proportion of formal fees to total costs to the consumer and the unpredictable nature of informal fees and other costs of access may actually work against formal fee exemption mechanisms. Even though little is known about how well fee and waiver mechanisms function for maternal health services, it is important to understand whether exemption mechanisms alone hold promise for protecting access for the poor or whether the mechanisms need to be supplemented with other strategies. This study was conducted simultaneously in five countries: Egypt, India (Uttaranchal), Kenya, Peru, and Vietnam. The objectives were to survey actual costs to consumers for antenatal and delivery care; survey current fee and waiver mechanisms; assess the degree to which these mechanisms function; assess the degree to which informal costs to consumers constitute a barrier to service; and review current policies and practices regarding the setting of fees and the collection, retention, and use of revenue.
  • The POLICY Project prepared this paper as part of a study of the status of family planning in four countries hit hard by HIV/AIDS: Ethiopia, Kenya, Zambia, and Cambodia.
    Working Paper 17- FP HIV Integration Synthesis.doc
  • The 1994 ICPD in Cairo shifted family planning program attention from a focus on achieving demographic targets to meeting individual needs of women for family planning and reproductive health services. Several governments in developing countries are responding by placing increased emphasis on program quality, meeting the expressed needs of clients, and placing less emphasis on achieving quantitative indicators of program performance. This report summarizes some of the changes in performance monitoring taking place in selected countries. There is considerable variability in how countries are making this transition. While Indonesia has been one of the most successful developing countries to meet its demographic objectives, it has recently made great strides in shifting the focus of its family planning program from a target-driven program to one based on the concept of understanding and fulfilling the needs and preferences of the family. Work is now underway to operationalize the policy at the field level, incorporate the approach in national and local planning, and devise strategies for collecting information that will allow assessment of its success. • In the Philippines, focus is placed on improving maternal and child health and meeting the reproductive intentions of women. Work is proceeding to improve the national MIS, make better use of existing data from a variety of sources to produce an annual status report for the Philippine Family Planning Program, as well as to strengthen monitoring systems at the local level. There is currently a lot of variability in capabilities by local government unit (LGU). While pilot approaches are being tested in a few LGUs, it is unclear to what extent these will be endorsed by either the Department of Health or other LGUs. • In Zimbabwe, greater attention is being paid to reproductive health in service provision, particularly STD treatment and prevention. A new report form is being tested to ascertain more clearly the quality of care provided and patterns of method switching. The next five-year plan, to be developed during 1996, is expected to formalize the new reproductive health strategy. • Increased emphasis is being placed on reproductive health in Mexico, although it's too early to know how the performance monitoring system will evolve to address these new concerns. While experience is beginning to accumulate, shifting from advocacy for a reproductive health approach to program implementation at national, subnational, and local levels will require much new work to obtain timely, accurate information for planning, implementation, and monitoring of reproductive health programs.
  • In the effort to develop dynamic national family planning service systems, USAID has supported a sustained set of initiatives to strengthen private sector service delivery. Many of these, like the SOMARC, Enterprise, PROFIT, and Initiatives projects, have focused primarily on the operational side of program expansion (e.g., training private providers, helping clinic managers develop business and financial plans, improving management efficiency, and marketing products and services). This paper looks at how activities in the policy domain often determine the success or failure of efforts to develop private sector services. This paper examines lessons learned in USAID's OPTIONS and POLICY projects, both of which have worked extensively in developing countries to foster private sector involvement in family planning and reproductive health care. It presents lessons learned during implementation of these activities and emphasizes ways to strengthen the policy climate and plan for service expansion. Following a general discussion of lessons learned, the paper includes examples from 11 countries that describe efforts to remove impediments to private sector participation and effective health care financing. The issues range from taxation of imported commodities in the Philippines to divestiture of contraceptive brands in Jamaica to market segmentation in Egypt. In sum, the country examples illustrate the steps governments can take to ensure adequate financing of their programs, use their resources efficiently, and tap the extensive resources of the private sector. Summary of Lessons Learned: • Governments should ensure that sufficient resources are available for services from both public and private sector sources. • Government subsidies should be targeted to appropriate clientele. • Efforts to increase private sector participation in family planning service delivery should begin with the public sector. • Many public sector clients can afford to pay for needed services either in part or in full. • Legal and regulatory barriers can impede the involvement/performance of the private sector. • Governments have a fundamental role in regulating the quality of private sector health services; however, many governments lack experience in regulating the private sector. • The private sector is often able and willing to work with the public sector as a partner. • Donors and cooperating agencies need to communicate and collaborate to ensure synergy of efforts in the field.
  • The 1994 ICPD expanded the population agenda far beyond family planning. Reproductive health, and the preventive and curative services that could assure it in developing countries, became a key objective accepted by the more than 180 signatory governments. Left unclear were the cost of this expansion and the source of funds to finance it. To fill that cost-estimation gap, the authors reviewed 160 publications issued between 1970 and June 1997, most of them about the time of the Cairo conference. The studies highlighted in this paper offer some quantitative data on the costs of reproductive health services identified as part of the Cairo agenda. In this review, cost data are reported for eight categories of reproductive health interventions: family planning, safe motherhood programs, maternal/infant nutrition and immunizations, obstetric care, abortion/postabortion care, STI/HIV/AIDS, reproductive cancers, and miscellaneous gynecology. The review of family planning cost data is treated differently from other reproductive health interventions. For the seven non-family-planning reproductive health elements, there were about 75 examples (29 studies) of unit cost data. We found only 17 instances of cost-effectiveness estimates (i.e., quantitative relations established between costs and health outcomes) in 15 studies. Furthermore, there were only six studies that referred to inter-disease measures of health outcomes, such as disability-adjusted life-years (DALYs), producing 16 cost-effectiveness estimates. This literature review identifies the gaps in cost information regarding potential reproductive health interventions within the individual reproductive health elements; within geographic regions; and by costing methods. First, about one-half of the expected reproductive health (mostly clinical) services have been costed in at least one setting. Second, only four countries—Bolivia, Ecuador, Mexico, and Zimbabwe—have cost information for more than two services. Third, there is considerable variability in the costing methods applied. Some of the reviewed studies do not clearly report the method used and the assumptions made in calculating the cost results. Nor do they provide all the necessary data to make recalculation of the results possible. Even given valid and replicable measurement, the cost-estimates as presented are generally not comparable because of the lack of a common denominator. This review recommends that "filling the gaps" should be based on local information needs, and that issues of quality, access, and integrated service delivery require closer attention. In addition, the ongoing debate about existing measures of health outcomes suggests that alternative methods for comparing health interventions merit attention. Finally, collecting the cost information available in developing countries (i.e., not in the international literature) would be useful both to local decision makers and others involved in setting priorities and allocating resources for health services.
  • As countries try to allocate limited public sector funds for family planning effectively and efficiently, there is increasing interest in understanding and measuring clients' ability to pay for services. If public funds are not sufficient to serve the entire population, they should be targeted to users who are less able to pay. Ideally, women with some ability to pay for health care services should use the private sector, at least for less costly contraceptive methods. This paper presents a methodology for describing the extent to which government subsidies are efficiently applied, that is, to users who could not otherwise afford their contraceptive methods. It examines national family planning markets that include both government and commercial providers and in which government resources are not sufficient to provide universal family planning coverage. Using Demographic and Health Surveys (DHS) data from 11 countries, the analysis shows that the commercial sector market share is higher for less expensive contraceptive methods and that women who make use of private sector maternal and child health care services are more likely to use commercial outlets for contraception. Distortions in this general pattern emerge in countries that over-subsidize certain contraceptive methods, particularly oral contraceptives, to the detriment of the commercial sector. Findings from this analysis can provide insights for further exploration of potential problems such as untargeted government subsidies for less expensive methods or lack of access for clinical methods.
  • The improved nutritional status of women, particularly during their childbearing years, is an important element of reproductive health. Efforts to improve women's nutrition and health include increasing food intake at all stages of the life cycle, eliminating micronutrient deficiencies, preventing and treating parasitic infections, reducing women's workload, and reducing unwanted fertility. This paper outlines the critical role of maternal nutrition and, in particular, micronutrients to reproductive health. The micronutrient status of women in developing countries affects their health during pregnancy and lactation, the outcomes of their pregnancies, and the health of their infants. For women who are vitamin and nutrient deficient, improving micronutrient intake can be an important means of reducing maternal morbidity and mortality. Micronutrient malnutrition is primarily the result of inadequate dietary intake. Dietary surveys in developing countries have consistently shown that multiple micronutrient deficiencies, rather than single deficiencies, are common, and that low dietary intakes and poor bioavailability of micronutrients account for the high prevalence of these multiple deficiencies. Recent evidence concerning increased micronutrient supplementation suggests the following findings: • Enhancing vitamin A intake reduces maternal mortality. • Increasing calcium and magnesium intake can reduce the risk of death from eclampsia. • Ensuring adequate intake of iron, zinc, iodine, calcium, magnesium, and folic acid during pregnancy can improve pregnancy outcome. • Increasing the intake of folic acid before pregnancy can reduce birth defects. • Providing zinc, calcium, and magnesium supplements during pregnancy can improve birthweight and reduce prematurity, especially among high-risk women. • Improving the maternal intake of many nutrients directly enhances the quality of breast milk. In addition, micronutrients play an essential role in the function of the immune system, and deficiencies in them influence the rate, duration, and severity of infections. Infection rates during pregnancy or lactation, including reproductive tract infections, increase because of deficiencies in iron, vitamin A, and zinc. Also, low serum vitamin A levels in pregnant women have been associated with increased transmission of HIV to infants and with increased transition from HIV to AIDS and increased mortality from AIDS among infants. The consequences of malnutrition affect the ability of women to sustain work and care for their families. Solutions to prevent or eliminate micronutrient malnutrition include nutrient supplementation of women of childbearing age before and after pregnancy through repeated reproductive cycles. Combined supplements are usually more effective in improving micronutrient status than single supplements, since women are usually deficient in more than one micronutrient. In addition, universal or targeted food fortification, which has proved cost-effective, can be an important strategy in preventing micronutrient malnutrition.
  • The need to meet the family planning needs of men and women, coupled with dwindling donor resources, is forcing family planning programs worldwide to confront increasingly difficult financial challenges. One option for expanding the resource base for family planning and reproductive health services in developing countries is to promote the growth of the commercial family planning sector. Using DHS data for 45 countries, this paper demonstrates that (1) the commercial sector plays an important role in national family planning markets, even in countries where contraceptive prevalence is low; and (2) the commercial family planning sector does not always develop coincidentally as prevalence grows or as programs mature. If the commercial sector does not necessarily gain market share as prevalence grows, what factors account for differences in commercial market shares across countries? This paper examines three sets of factors to explain variations in commercial market share across countries: • Microeconomic or household factors. Characteristics of individuals, such as ability to pay or knowledge of contraception, may make them more likely to use the commercial sector. • Macroeconomic or business climate factors. Characteristics of a country and its economy may lead to a larger commercial market share for contraceptive services and commodities. • Programmatic factors. Characteristics of a family planning program, such as government support and method mix, may lead to a larger commercial market share. The commercial market share for family planning is related to many factors, which can be grouped in two categories: external factors, over which there is no control, such as per capita income and the level of urbanization, but which can be exploited or understood as a program constraint; and programmatic factors, which are under the direct or indirect control of the program, such as public sector pricing or program effort. The cross-national analysis shows that broad-based purchasing power, improved knowledge of reproductive health, critical densities of population, and appropriate public policy are each associated with relatively strong commercial sectors. This paper recommends that public health policymakers take steps to integrate the commercial sector into their programs by developing economic and policy environments supportive of its expansion. In many countries, family planning has been provided as if it were a public good. Large public programs were designed to expand service delivery in public sector facilities, while limited attention was paid to growth of the commercial sector, likely assuming commercial sector share would grow as a consequence of growth in general public interest in family planning. This study identifies factors for which key policy support may be able to generate increased use of the commercial sector for family planning.
  • The purpose of this paper is to familiarize policymakers with market segmentation analysis and its role in supporting more efficient and effective resource use. Specifically, the paper summarizes how market segmentation analysis helped initiate public/private dialogue to guide resource allocation decisions in four countries: Turkey, India, Morocco, and Brazil. In Morocco and Turkey, market segmentation analysis results were central to public/private reproductive health finance discussions and guided public sector decisions to concentrate resources more heavily on the most vulnerable and needy population groups. In Brazil and India, market segmentation analysis findings helped guide reproductive health finance discussions between donors and the private sector that led ultimately to private sector expansion.
  • At the 1994 International Conference on Population and Development (ICPD) in Cairo, more than 180 countries, including 38 sub–Saharan African countries, drafted and ratified the Programme of Action that includes support for the provision of sexual and reproductive health education, information, and services to adolescents. Addressing adolescent reproductive health (ARH) issues is particularly crucial in sub–Saharan Africa, where rates of maternal mortality, unsafe abortion, and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), among youth are the highest in the world. Despite the obvious importance of the topic, ARH remains a controversial subject in the sub–Saharan region. Consequently, the exercise of caution in approaching the subject has led to a gap between the declarations of governmental officials and the actual design of reproductive health policies and programs geared toward youth. This paper provides a practical means of assessing reproductive health policies and programs geared toward adolescents. First, it presents major elements of ARH policy and program development and sets benchmarks against which future policy and program development can be measured. Second, the paper compares ARH policy and program development in three Francophone African countries: Burkina Faso, Cameroon, and Togo.
  • Despite some attempts to integrate family planning with sexually transmitted infection (STI) and HIV/AIDS services, policies and programs continue to treat them as unrelated areas of intervention. Furthermore, international attention to the HIV/AIDS pandemic has overshadowed attention to family planning, particularly in Africa where the HIV/AIDS epidemic is most acute. Yet family planning is closely related to two components of HIV/AIDS services: prevention of mother-to-child transmission (PMTCT) and voluntary counseling and testing (VCT). Is there a role for family planning in the context of HIV/AIDS programs? This paper analyzes how international guidelines, national HIV/AIDS policies and PMTCT and VCT policies have addressed family planning in 16 high-HIV prevalence countries. It also describes major gaps in the various countries’ policy environment.